Name *

First Name

Last Name

Date *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you regularly active in sports and/or exercise? *

Yes

No

Who lives with you? *

Please check all that apply.

Spouse or Partner

Roommate(s)

Child(ren)

Pet(s)

Other family (e.g. parent, grandparent, sibling, etc.)

Who does most of the grocery shopping in your household? *

Please check all that apply.

Me

Spouse

Roommate(s)

Child(ren)

Other family

Who does most of the cooking in your household? *

Please check all that apply.

Me

Spouse

Roommate(s)

Child(ren)

Other family

Who decides on most of the menus/meal types in your household? *

Please check all that apply.

Me

Spouse

Roommate(s)

Child(ren)

Other family

Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? *

Yes

No

Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries? *

Yes

No

Right now, are you taking any medications, either over-the-counter or prescription? *

Yes

No

In an average week, which do you spend time doing... *

Please check all that apply.

In paid employment

Taking care of others

At school or doing school work

Doing other unpaid work

Traveling and/or commuting

Volunteering

On average, how many hours per night do you sleep? *

4 or fewer hours

5-6 hours

7-8 hours

9 or more hours